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Y4 Obstetrics and Gynaecology > Bleeding in pregnancy > Flashcards

Bleeding in pregnancy Flashcards

1
Q

Define what antepartum haemorrhage is

A

This is bleeding from or into the genital tract occurring from ≥ 24 weeks + 0 until the end of the 2nd stage of labour (i.e. birth of the baby)

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2
Q

Bleeding in pregnancy can be split into 2 categories what are they?

A
  1. Bleeding in early pregnancy (<24weeks)
  2. And bleeding in late pregnancy (≥24weeks+0)
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3
Q

What is the other name given to bleeding in late pregnancy ?

A

Antepartum haemorrhage

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4
Q

Appreciate this:

Death from obsetric haemorrhage is very uncommon in the UK but globally it is very common consisting of up to 50% of maternal deaths each year

A
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5
Q

List the functions of the placenta

A
  • It is the sole source of nutrition for the fetus from 6weeks
  • Gas transfer occurs here
  • Metabolism/ waste disposal for the fetus
  • Hormone production - HPL (human chorionic sommatotropin) & human growth hormone (HGH-V)
  • It is protective acting as a filter
  • Very vascular but is normal expelled harmlessly
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6
Q

List the causes of antepartum haemorrhage

A

Dangerous ones:

  • Placenta praevia
  • Placental abruption
  • Vasa praevia

Local causes:

  • Cervical ectropion
  • Polyps
  • Cancer
  • Infection e.g. cervicitis, STI

Other:

  • Uterine rupture
  • 40% of the time there is no apparent cause
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7
Q

List the other main differentials for APH ?

A
  1. Haemorrhoids = enlarged blood vessels (swellings) found inside/ around rectum & anus that can bleed
  2. Cystitis = inflammation of the bladder
  3. Heavy show; bloody show = the passage of small amount of blood/ blood-tinged mucus through the vagina near the end of pregnancy, it can occur just before labour or in the early stages of it
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8
Q

Quantifying APH, define the following:

  1. Spotting
  2. Minor haemorrhage
  3. Major haemorrhage
  4. Massive haemorrhage
A
  1. Spotting = staining, streaking or blood spotting noticed on underwear or sanitary protection
  2. Minor haemorrhage = blood loss < 50ml that has settled
  3. Major haemorrhage = blood loss of 50-1000ml, with no signs of clinical shock
  4. Massive haemorrhage = blood loss > 1000ml &/or signs of clinical shock
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9
Q

What are the clinical signs of shock?

A
  • Low BP
  • Altered mental state - reduced alterness, confusion, sleepiness
  • Cold, moist skin, hands and eet may be blue or pale
  • Weak or rapid pulse (or both)
  • Rapid breathing (increased RR) & hyperventilation
  • Decreased urine output
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10
Q

Define what placental abruption is and how common it is

A
  • This is separation of a normally implanted placenta - it may be separated partially or totally before birth of the fetus
  • It accounts for 30% of APH
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11
Q

How is placental abruption diagnosed ?

A

Clinically

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12
Q

Describe the pathology of placental abruption

A
  1. It occurs due to vasospasm followed by arteriole rupture
  2. Blood then escapes into the amniotic sac or further under the placenta & into the myometrium, causing tissue contraction & interruption of placental circulation which causes hypoxia and inturn a Couvelaire uterus

Note couvelaire uterus = a pregnant uterus in which the placenta has detacted prematurely with leakage (extravasation) of blood into the uterus myometrium

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13
Q

List the risk factors for placental abruption

A
  • Unknown
  • PET/HTN
  • Trauma – blunt, forceful, domestic violence
  • Smoking/Cocaine/Amphetamine
  • Medical Thrombophilias/Renal diseases/Diabetes
  • Poly-hydramnios, Multiple pregnancy, Preterm-PROM
  • Abnormal placenta – The ‘Sick placenta’
  • Previous abruption - recurrence 10%
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14
Q

What are the symptoms of placental abruption

A
  • Severe abdo pain which is continuous (unlike labour pain which is intermittent due to contractions)
  • Bleeding (may be concealed)
  • Backache
  • Preterm labour
  • May present with maternal collapse
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15
Q

What are the signs of placental abruption ?

A
  • Unwell distressed patient
  • Uterine tenderness
  • Woody hard uterus
  • Vaginal bleeding (may be small or large volume as bleeding can be concealed so signs may be inconsistent with observed blood loss i.e. small blood loss but severe signs)
  • Fetal parts difficult to identify
  • Uterus large for dates (LFD) or normal
  • May be in pre-term labour
  • FH (fetal heart) bradycardia/absent (IUD)
  • CTG shows irritable uterus - 1 contraction/min, FH: loss of variability, deccelerations seen
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16
Q

What are the keys steps in management of a women presenting with placental abruption ?

A
  1. Resuscitate the mother
  2. Assessment/ diagnosis of the condition
  3. Delivery
  4. Management of complications
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17
Q

What is done to resuscitate a mother with placental aburption ?

A
  • ABCDE assessement
  • 2 large bore cannulas
  • FBC, clotting screen, LFT’s, Us & Es, Cross-matching, Kleinhauer test
  • IV fluids
  • Catheterise and monitor
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18
Q

What is done to in the assessment of a mother with placental aburption ?

A
  • Assess FH on CTG
  • Perform U/S if no FH on CTG to evlaute the FH
  • No reliable diagnostic test: U/S will fail to detect 3/4 of abruptions so diagnosis of abruption is primarily clinical
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19
Q

What the delivery management of a women with palcental abruption ?

A

For moderate & severe abruption/APH:

  • Women with APH & associated maternal &/or fetal compromise are required to be delivered immediately by C-section or artificial rupture of membranes & induction of labour

Minor aburption/APH:

  • Expectant management only used for minor cases (all time for steroid cover)
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20
Q

List the potential maternal complications of placental abruption

A
  • Hypovolaemic shock
  • Anaemia
  • PPH
  • Renal failure from renal tubular necrosis
  • Coagulopathy (if DIC develops)
  • Infection
  • Thromboembolism
  • Prolonged hosp stay
  • Death (rare)
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21
Q

List the potential fetal complications of placental abruption

A
  • IUD (14%)
  • SGA & IUGR
  • Prematurity
  • Hypoxia
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22
Q

When are steroids given to pregnant women ?

A
  • A single course of steroids is given to women between 24+0 and 34+6 weeks who are at risk fo preterm birth
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23
Q

Following APH from aburption or unexplained origin, if the women is still pregnant and has not given birth what should be done ?

A
  • Pregnnancy should be reclassified as high risk and Serial U/S for fetal growth should be performed
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24
Q

What investigation should be avoided if placenta praevia is a possibility for the cause of APH?

A

Vaginal examination as it can cause catastrophic bleeding

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25
Q

What is given to help prevent placental abruption ?

A
  • Try to stop women smoking, using cocaine or amphetamines
  • Women with thrombophilia (anti-phos syndrome) given LMWH + low dose aspirin
  • Women at risk of abruption not those who have APS given low dose aspirin
26
Q

Define what placenta praevia is

A

This is where the placenta is partially or totally implanted in the lower uterine segment known as a ‘low lying placenta’

27
Q

What percentage of APH does placenta praevia account for ?

A

20%

28
Q

What are the risk factors for developing placenta praevia ?

A
  • Previous placenta praevia
  • Asian
  • Smoking
  • Previous termination
  • Multiparity
  • Advanced maternal age >40
  • Mutplie pregnancies
  • Assisted conception
  • Deficient endometrium due to - uterine scar, endometritis, manual removal of placenta, currettage, submucous fibroid
29
Q

State the classification of placenta praevia (I to IV)

A
  • I - placenta reaches lower segment but not the internal os
  • II - placenta reaches internal os but doesn’t cover it
  • III - placenta covers the internal os before dilation but not when dilated
  • IV - placenta completely covers the internal os
30
Q

State the classification of placenta praevia into major and minor

A
  • Minor praevia = if the leading edge of the placenta is in the lower uterine segment but not covering the cervical os
  • Major praevia = if placenta lies over the internal cervical os
31
Q

What are the signs and symptoms of placenta praevia

A
  • Painless vaginal bleeding occurring > 24weeks
  • Bleeding usually provoked by coitus (sexual intercorse)
  • Bleeding can range from minor e.g. spotting to severe
  • Patients condition is directly proportional to amount of observed bleeding (unlike abruption)
  • Uterus is soft & non-tender
  • Presenting part is high
  • Malpresentation e.g. breech, transverse, oblique (if placenta is in an odd position so will the baby be)
  • CTG usually normal
32
Q

How is placenta praevia diagnosed ?

A

Transvaginal U/S

  • Note check their anomaly scan at 20 weeks as this often picks it up
  • Followed up and then confirmed at 32-34 week scan
33
Q

What are the 3 keys steps in the management of a pregnant women bleeding from placenta praevia ?

A
  1. Admit & resuscitate
  2. Monitor FH
  3. Delivery
34
Q

In a women bleeding from placenta praevia what resucitative measures are required ?

A
  • 2 large bore cannulas
  • FBC, clotting screen, LFT’s, Us & Es, Kleihauer test, X-match 4-6 units of RBC’s
  • May need major haemorrhage protocol
  • IV fluids or transfusion
  • Anti-D if Rh -ve

(basically same as for placental abruption)

35
Q

In a women bleeding from placenta praevia what FH monitoring is required ?

A
  • CTG
  • U/S carried out if FH not detected on CTG (same as placental abruption)
36
Q

In a women bleeding from placenta praevia what are the management options for delivery ?

A

Conservative/expectant management:

  • Should be an inpatient for at least 24hrs until bleeding has stopped
  • Monitor FH with CTG after 28 weeks
  • Steroids course given if between weeks 24 to 34+6
  • MgSO4 given if planning delivery between 24-32 weeks
  • Serial U/S also recommended
  • On pelvic rest, avoiding sexual intercourse

If not stable then may need to do C-section

37
Q

What determines the mode of delivery in women with placenta praevia

A
  • C-section (with consultant present) done if placenta is < 2cm from the cervical os
  • Vaginal delivery done if placenta > 2cm away from cervical os & no malpresentation

Major bleeding may require preterm delivery

C-section at 37 - 38 weeks if there has been prior bleeding in pregnancy or suspected/confirmed placenta accreta

C-section at 38-39 weeks if there has not been bleeding in pregnancy

38
Q

What is the association of increasing the number of C-sections you have had done and placental abnormalities

A

The risk of placenta praevia & accreta both increase with the number of C-sections you have had done

39
Q

Read over abruption vs praevia:

Abruption:

  • Shock out of keeping with visible blood loss
  • Pain constant
  • Tender, tense uterus
  • Normal lie & presentation of baby
  • FH - absent/distressed
  • Coagulation problems associated
  • Beware of PET, DIC, anuria

Praevia:

  • Shock in proportion to visible blood loss
  • No pain
  • Uterus soft & non tender
  • Lie & presentation of baby may be abnormal
  • FH usually normal
  • Coagulation problems rare
  • Small bleeds before large
A
40
Q

Define what placenta accreta is

A

Planceta accreta is the general term for whe the plaenta invades & is inseperable from the uterine wall. There is 3 subtypes:

  1. Placenta accreta = placenta attaches to the myometrium
  2. Planceta increta = placenta invades into the myometrium
  3. Placenta pancreta = placenta invades through the perimetrium (serosa)
41
Q

What are the 2 major risk factors for placenta accreta ?

A
  1. It occurs in 5-10% of placenta praevias
  2. Risk of it increases with increasing no. of C-sections
42
Q

When does placenta accerta become a problem?

A

It becomes a problem during delivery when the placenta does not completely separate from the uterus & is then followed by massive obstetric haemorrhage (>3L expected)

43
Q

How is placenta accreta diagnosed ?

A

1st line = U/S +/- MRI

Antenatal MRI can be used as well to assess depth of invasion etc

44
Q

What is the management of placenta accreta ?

A
  • Prophylactic internal iliac artery balloon occlusion done
  • Then it is generally recommended a planned cesarean hysterectomy is done after weeks 36-37 if possible
  • Conservative management should not be done if women is already bleeding
45
Q

Define what uterine rupture is

A

Defined as a full thickness opening of the uterus

46
Q

What are the risk factors for uterine rupture?

A
  • Previous C-section/uterine surgery
  • Multiparity & use of syntocin
  • Obstructed labour
  • Usually occurs in labour
47
Q

What are the signs and symptoms of uterine rupture ?

A
  • Severe abdo pain
  • Shoulder-tip pain
  • Maternal collapse
  • PV bleeding (vaginal)
  • Intrapartum loss of contractions
  • Fetal distress/ IUD
  • Puritanism - vomiting, pain or abdo tenderness & shock
48
Q

What is the management of uterine rupture ?

A

Urgent resuscitation & surgical management

49
Q

What is the resuscitation management of uterine rupture ?

A
  • 2 large bore cannulas
  • FBC, clotting screen, LFT’s, Us and Es, Kleihauer test, X-match 4-6 units of RBC’s
  • May need major haemorrhage protocol
  • IV fluids or transfusions
  • Anti-D if Rh -ve

Same as all other resus management

50
Q

What is the surgical management of uterine rupture ?

A

Laparotomy (if uterus rupture small repair, if large hysterectomy may be done) & deliver the baby via C-section

51
Q

Define what vasa praevia is

A

Defined as fetal vessels coursing through the membranes over the internal cervical os, unprotected by placental tissue or umbilical cord

52
Q

What are the risk factors for vasa praevia ?

A
  • Placental anomalies such as bilobed placenta where fetal vessels run through the membranes joining the separate lobes together
  • Placenta praevia
  • Multiple pregnancy
  • IVF
53
Q

How does vasa praevia often present ?

A
  • Presents with fresh vaginal bleeding at the time of membrane rupture + FH abnormalities - deccelerations, bradycardia, sinusoidal tract or fetal demise
  • Note blood volume may be very small as fetal blood volume 200ml at term ==> small amounts of blood can have serious consequences
54
Q

What is the fetal mortality rate of vasa praevia ?

A

60%

55
Q

How is vasa praevia diagnosed ?

A

It may be diagnosed on antenatal U/S + doppler

56
Q

What is the management of vasa praevia ?

A

C-section is fetal compromise/ demise present

57
Q

When taking a history about APH what should you ask about ?

A
  • Bleeding - quantify
  • Pain - SCORATES
  • Contractions - freq and strength
  • Fetal movements - change from normal ?
  • Post-coital - pain or bleeding ?
  • Smear history
  • Antenatal scan history - U/S
58
Q

Go over the antenatal admission criteria for APH

A

Any history of acute bleeding 23 – 32 weeks:

  • Min stay of 24 hours clear of bleeding

Recurrent bleeding after 28 weeks:

  • Min stay of 72 hours
  • Consider need to be admitted until delivery

Any bleeding after 32 weeks:

  • Min stay of 72 hours
  • Consider need to be admitted until delivery

Major placenta praevia after 36 weeks with no bleeding:

  • Consider the social circumstances
  • Consider other obstetric factors
  • Consider need for admission until delivery
  • Consultant decision
59
Q

Should steroids be given to a women who presents with APH ?

A

Single course is given if presents between 24 to 36+6 weeks (greatest effect between 24 to 34+6 but still given up until 37 weeks essentially)

60
Q

Should antenatal care be adapted for women with APH ?

A

Yes any from abruption, praevia or unclassified are reclassified as high risk and have consultant led care with serial U/S for fetal growth measurements

61
Q

Go over the principles of labour & delivery

A
  • If fetal death diagnosed then vaginal delivery
  • If fetal compromise then C-section
  • Women with APH & associated maternal &/or fetal compromise are to be delivery immediately
62
Q

What is the purpose of steroids prior to delivery in preterm babies ?

A
  • It promotes fetal lung surfactant production
  • It ↓ neonatal RDSby up to 50% if administered 24-48h before delivery
  • Betamethasone preferred to Dexamethasone
  • 1 course = 12mg Betamethasone IM X2 injections 12 hours apart

Y4 Obstetrics and Gynaecology (63 decks)

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